BMJ: first published as 10.1136/bmj.k4907 on 28 November 2018. Downloaded from http://www.bmj.com/ on 30 November 2022 at University of N S Wales 1247645.
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BMJ 2018;363:k4907 doi: 10.1136/bmj.k4907 (Published 28 November 2018)
Analysis
QUALITY IMPROVEMENT
Understanding organisational culture for healthcare
quality improvement
OPEN ACCESS
Russell Mannion and Huw Davies explore how notions of culture relate to service performance,
quality, safety, and improvement
1 2
Russell Mannion professor , Huw Davies professor
1
Health Services Management Centre, University of Birmingham, Birmingham, UK; 2School of Management, University of St Andrews, St Andrews,
UK
Key messages
Organisational culture represents the shared ways of thinking, feeling,
and behaving in healthcare organisations.
Healthcare organisations are best viewed as comprising multiple
subcultures, which may be driving forces for change or may undermine
quality improvement initiatives
A growing body of evidence links cultures and quality, but we need a more
nuanced and sophisticated understandings of cultural dynamics
Although culture is often identified as the primary culprit in healthcare
scandals, with cultural reform required to remedy failings, such simplistic
diagnoses and prescriptions lack depth and specificity
If we believe the headlines, health services are suffering
epidemics of cultural shortcomings. Extensive enquiries into
failures and scandals in the NHS over several decades have
indicated aspects of hospital culture as leading to those
failings.(box 1).1 2 The recent report into over 450 premature
deaths at Gosport War Memorial Hospital mentions culture 21
times.3 After such reports, widespread and fundamental cultural
change is typically prescribed as the remedy (box 1).4 5
Correspondence to: R Mannion r.mannion@bham.ac.uk
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Page 1 of 4
ANALYSIS
Box 1: Centrality of culture to healthcare scandals: from
Kennedy to Francis
From Ian Kennedy’s review of the failings in paediatric cardiac surgery in
Bristol during the 1980s and 90s2 to Robert Francis’s inquiry into the systemic
failings at Mid Staffordshire Hospital Trust over a decade later,1 culture has
been implicated.
Culture as culprit
“There was an insular ‘club’ culture [at Bristol], in which it was difficult for
anyone to stand out, to press for change, or to raise questions and concerns”
(p302)2
“Aspects of a negative culture have emerged at all levels of the NHS system.
These include: a lack of consideration of risks to patients, defensiveness,
looking inwards not outwards, secrecy, misplaced assumptions of trust,
acceptance of poor standards, and, above all, a failure to put the patient first
in everything done” (p2357)1
Culture as remedy
“The culture of healthcare, which so critically affects all other aspects of the
service which patients receive, must develop and change” (p277)2
“The extent of the failure of the system shown in this inquiry’s report suggests
that a fundamental culture change is needed” (p65)1
Ideas of culture are also central to quality improvement methods.
From basic clinical audit to sustained improvement
“collaboratives,” business process re-engineering, Lean Six
Sigma, the need for cultural reorientation is part of the
challenge.6 Yet although the language of organisational
culture—sometimes culprit, sometimes remedy, and always
part of the underlying substrate at which change is directed—has
some immediate appeal, we should ask deeper questions. What
actually is culture in health services? How does culture relate
to healthcare quality, safety, and performance? And can
changing culture lead to improvements in care and organisational
performance?
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BMJ 2018;363:k4907 doi: 10.1136/bmj.k4907 (Published 28 November 2018)
Greater specificity around both culture and performance enables
us to understand more precisely the possible relations between
them: quality improvement work is ill served by broadbrush
accounts of culture and service quality. We seek to move past
the use of culture as simply a rhetorical tool used by politicians
and in policy edicts. Instead, we outline a more nuanced account
of the social dynamics of healthcare services.
What is culture in this context?
Healthcare organisational culture (from here, just culture) is a
metaphor for some of the softer, less visible, aspects of health
service organisations and how these become manifest in patterns
of care. The study of organisational practices derives from social
anthropologists’ approaches to the study of indigenous people:
both seek to unravel the dynamics of unfamiliar “tribes.” The
view that culture can be managed to remedy past deficits and
produce desirable future outcomes is often smuggled in through
this re-application of the ideas of culture to organisations. This
view needs some critical scrutiny,5 one that explores a more
nuanced account of organisational culture in healthcare.
In one common framing,7 the shared aspects of organisational
life—the culture—are categorised as three (increasingly
obscured) layers (box 2). First, and most visible, are the physical
artefacts and arrangements, as well as the associated behaviours
that get things done. These visible manifestations of culture are
seen in how estate, equipment, and staff are configured and
used, and in the range of behaviours seen as normal and
acceptable. These include the embedded and accepted care
pathways, clinical practices, and communication patterns,
sometimes referred to as “the way things are done around here.”
Box 2: Three levels of organisational culture in healthcare7 8
Visible manifestations of healthcare culture include the distribution of services
and roles between service organisations (such as the long established divides
between secondary and primary care and between health and social care),
the physical layouts of facilities (receptionists behind desks and doctors in
consulting rooms), the established pathways through care (including the
ubiquitous outpatients appointment), demarcation between staff groups in
activities performed (and the tussles that challenge or reinforce these), staffing
practices and reporting arrangements, dress codes (such as different coloured
scrubs for different staff groups in emergency departments), reward systems
(pay and pensions, but also the less tangible rewards of autonomy and
respect), and the local rituals and ceremonies that support approved practices.
Visible manifestations of culture (sometimes called artefacts) also include the
established ways (both formal and informal) of tackling quality improvement
and patient safety, the management of risk, and the accepted ways of
responding to staff concerns and patient feedback or complaints.
Shared ways of thinking include the values and beliefs used to justify and
sustain the visible manifestations above and their associated behaviours, as
well as the rationales put forward for doing things differently. This might include
prevailing views on patient needs, autonomy, and dignity; ideas about evidence
for action; and expectations about safety, quality, clinical performance, and
service improvement.
Deeper shared assumptions are the (largely unconscious and unexamined)
underpinnings of day-to-day practice. These might include ideas about
appropriate professional roles and delineations; expectations about patients’
and carers’ knowledge and dispositions; and assumptions about the relative
power of healthcare professionals—collectively and individually—in the health
system.
The second level is the shared ways of thinking that are used to
justify the visible manifestations (box 2). This includes the
beliefs, values, and arguments used to sustain current patterns
of clinical practice. In this way, the local clinical culture is
expressed not only through what is done, but also how it is
talked about and justified.
Deeper still, and thus much less overt and accessible, are the
largely unspoken and often unconscious expectations and
presuppositions that underpin both dialogue and clinical practice
(the shared assumptions; box 2). Such attitudes may be formed
early, go deep, and be less amenable to modification.
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ANALYSIS
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These three levels are linked, of course, but not simply. Some
of the deeper values and assumptions are taught in early
professional education (the so-called hidden curriculum),
reinforced through ongoing professional interactions, and then
made visible as accepted practices. Other cultural manifestations
are created or shaped externally, perhaps by the macro policy
environment (for example, service configurations or reward
systems), but over time these can influence shared ways of
thinking and even deeper assumptions (about who or what is
valued, for example). As healthcare becomes more global, with
regular movement of care staff across national borders, major
shapers of the cultural aspects of care may also include national,
ethnic, or religious cultures.
Organisational culture, then, covers how things are arranged
and accomplished, as well as how they are talked about and
justified—that is, the stories and narratives about what is done
and why, and the presuppositions that underpin these. Taken
together these can reflect a shared and commonly understood
view of hospital life manifested in patterns of care, safety, and
risk. Although we focus on the hospital environment here, these
arrangements and narratives are found (albeit in different forms)
across all healthcare organisations from general practices to
community trusts. Those wishing and situated to improve
services need a sophisticated understanding of the social
dynamics and shared mental schema that underpin and reinforce
existing practices and inform their readiness to change.
An important additional layer of complexity is that shared
mental schema may be confined to subgroups within care
services, with important implications for patient experience and
service delivery.
One culture or many subcultures?
Healthcare organisations are notoriously varied, fractured by
specialty, occupational groupings, professional hierarchies, and
service lines. Some cultural attributes might be widespread and
stable, whereas others may be shared only in subgroups or held
only tentatively. Important subcultures are delineated most
obviously, as professional groups, and the faultlines are most
obvious as these groups compete for resources and status.9 Other
subcultures can emerge over time. Some staff groupings may
excel at articulating and enacting desirable values and practices,
which may be helpful to organisational goals; for example,
specialist teams or centres of excellence. Less helpfully perhaps,
other subgroups may actively work to undermine changes
promoted from external sources (often construed as
countercultures). Whether such countercultures reflect
unwarranted resistance to change or a more appropriate defence
of enduring values may be hard to discern and depends on both
perspective and context.
Hospitals, then, are a dynamic cultural mosaic made up of
multiple, complex, and overlapping subgroups with variably
shared assumptions, values, beliefs, and behaviours. Two of the
major professional groupings concerned with quality
improvement—doctors and managers—may differ in several
important ways, for example. Doctors may focus on patients as
individuals rather than groups and view evidence through a
positivist natural sciences lens. Managers may be more
concerned with patients as groups and value a social science
based experiential perspective.10 These cultural divergences
have important implications for collaborative work, especially
for people in hybrid roles who may either retain a cultural
allegiance to their base group or seek to adopt the cultural
orientations of their new role. They also form an important
target for purposeful cultural reform, which might sometimes
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BMJ 2018;363:k4907 doi: 10.1136/bmj.k4907 (Published 28 November 2018)
seek to strengthen current trends or at other times to inhibit
them.
In sum, specific subcultures may be powerful catalysts for
innovation and improvement or defenders of the status quo (for
good or ill); they can be useful safeguards against risk or covert
countercultures quietly undermining necessary reforms. Making
sense of this subcultural diversity should be an essential part of
any cultural “diagnosis” in seeking quality improvement.
Can culture be assessed and managed?
There are two distinctive views of culture. The first is optimistic
about the potential for purposive cultural management, seeing
culture as something that an organisation has— an attribute that
can be assessed and manipulated to improve care. By contrast,
the second view is more concerned with securing insights about
organisational dynamics, without focusing on whether they can
be manipulated. It sees organisational culture as something the
organisation simply is—an account of local dynamics not readily
separable from the organisational here-and-now.
These two perspectives take us down different routes of
assessing and managing local healthcare cultures. The first
emphasises the use of metrics to assess the prevalent
organisational culture around a performance domain, such as
patient safety. This approach assumes that a strong “safety
culture” is associated with better outcomes for patients. Such
measures may identify targets for managed change, and repeated
measurement may be used to gauge progress against cultural
objectives, with the hope that improvements in care will follow
(for example, the Safety Attitude Questionnaire; box 3). Many
such tools exist to assess different aspects of culture, although
the science behind them is often weak11 and their reliability and
validity are questionable.12
Box 3: Two examples of culture assessment tools directed at
patient safety
The Safety Attitude Questionnaire (SAQ) is a major (quantitative)
assessment tool developed in the United States and widely used in the NHS
to help organisations assess their safety culture and track changes over time.
The SAQ is a reworking and refinement of a similar tool widely used in the
aviation industry. There are various versions of the SAQ, but these typically
comprise some 60 survey items, designed in the form of five point Likert scales,
in six safety related domains: safety climate; team work; stress recognition;
perceptions of management; working conditions; and job satisfaction.
Completed by individuals, scores are then aggregated to give an indication
of the overall strength of the organisation’s extant safety culture.
The Manchester Patient Safety Framework is a facilitative (qualitative)
educational tool. It aims to provide insight into safety culture and how it can
be improved among teams and organisations. The tool explores nine
dimensions of patient safety and describes what an organisation would look
like at different levels of patient safety. Assessment is carried out in
facilitator-led workshops, and the assessments can be used to prompt
reflections, stimulate discussions, and understand strengths and weaknesses.
The second view seeks to explore local cultural dynamics, often
working through dialogue and perhaps using images and
narratives rather than measurement instruments. This view is
more modest about the potential for manager-led purposeful
change but may still see cultural assessment as part of an overall
influencing strategy (for example, the Manchester Patient Safety
Framework; box 3).
Although both perspectives draw on assessment tools, they do
so for different reasons: the first emphasising quantitative
measurement to identify targets for change and to track progress
(a summative approach); the second using qualitative insights
more discursively to prompt reflection, learning, and shared
actions (a more formative strategy). In practice, many
researchers, organisational leaders, and quality improvement
specialists will seek insights from across these approaches,
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ANALYSIS
BMJ: first published as 10.1136/bmj.k4907 on 28 November 2018. Downloaded from http://www.bmj.com/ on 30 November 2022 at University of N S Wales 1247645. Protected by copyright.
despite the (at times uncomfortable) accommodations needed
between their divergent assumptions.
Does culture matter?
It seems obvious that the shared, cultural aspects of
organisational life must have some bearing on organisational
outcomes. Yet because of the complexity of healthcare cultures
and the ambiguity around health service “success,” establishing
such links through research is not easy.13 Nonetheless, the most
recent systematic review of work in this area found a
“consistently positive association . . . between culture and
outcomes across multiple studies, settings, and countries.”14 So,
culture does seem to matter. Individual studies can also offer
important actionable insights, such as on the importance of
leadership, the need for balanced cultures, and on the contingent
nature of the relationships between culture and performance
(box 4).
Box 4: Insights from empirical study of the links between culture
and care
The importance of leadership
A recent intervention study (Leadership Saves Lives) focused on leadership
actions to promote positive changes in organisational culture in 10 hospitals
in the US. It found that changes in culture over a two year period varied
substantially between hospitals.15 16 In the hospitals that experienced substantial
and positive cultural shifts, changes were most prominent in specific domains,
such as perceptions of the learning environment, senior management support,
and psychological safety. Hospitals with marked positive shifts in culture also
experienced significant decreases in risk-standardised mortality rates (in this
case for treatment of acute myocardial infarction). These findings from the
US show which elements of culture need attention from hospital leaders—in
particular, fostering a learning environment, offering sustained and visible
senior management support to clinical teams, and ensuring that staff across
the organisation feel “psychologically safe” and able to speak up when things
are felt to be going wrong.
The need for balanced cultures
Research has shown that, in addition to cultural types, the balance between
different cultures is important. Shortell, for example, found that, in a sample
of chronic illness management teams, balance among team members relating
to the cultural values of participation, achievement, openness to innovation,
and adherence to rules and accountability was positively associated with both
the number and depth of changes aimed at improving the quality of care.17
The appearance of contingent relationships
The research indicates that there is no single “best” culture that always leads
to success across the full range of performance domains. Instead, the aspects
of performance valued in a given culture are enhanced in organisations with
strong congruence with that culture. Early studies in Canadian, UK, and US
hospitals found, for example, that hospitals with inwardly oriented cultures
that emphasised managing through informal interpersonal relationships
performed significantly above average on measures of employee loyalty and
commitment than those with outward looking cultures.18 Conversely, hospitals
with outward looking cultures and procedural management performed better
on measures of external stakeholder satisfaction. More recently, large scale
longitudinal research in English NHS hospital trusts19 replicated some of these
findings.
The influence of the wider organisational environment
A qualitative case study of six NHS hospitals found clear differences in the
cultural profile of “high” and “low” performing hospitals in terms of: leadership
style and management orientation; accountability and information systems;
human resource policies; and relations with other organisations in the local
health economy.20 Each of these provides potentially important targets for
purposeful cultural change aimed at performance improvement.
Clearly, the relations between culture and quality, safety, or
efficiency are unlikely to be straightforward. Culture, although
important, offers no “magic bullet”—the challenge becomes
one of understanding which components of culture might
influence which aspects of performance.
Moreover, any relations between culture and health service
outcomes are likely to be mutual and recursive: that is, perceived
performance is as likely to shape local healthcare cultures as
culture is to shape local healthcare performance. Virtuous circles
of high performance leading to reinforcing cultures of high
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BMJ 2018;363:k4907 doi: 10.1136/bmj.k4907 (Published 28 November 2018)
expectations may be seen, as can spirals into decline where
perceived performance failings lead to demoralisation and
resignation to those poor standards.20 In these arguments, we
can see how narrative practices about performance can have
important effects on local cultures and that this has implications
for clinician leaders, managers, and policy makers in how they
talk about and manage performance and improvement.
Conclusions
Too often the term culture is used as a metaphor for something
the organisation is thought to have. But acknowledging that
culture is a complex construct can allow more judicious
application of the concept. Paying greater attention to the
multilayered and multifaceted complexity underlying the
term—and recognising that many and varied cultural subgroups
make up our healthcare organisations—opens new avenues for
understanding the deeply social and discursive nature of complex
organisations.
How these insights are used in quality improvement depends
on both other conceptual framings of the healthcare setting, the
aspect of service quality or performance to be improved, and
on the precise nature of the quality improvement methods to be
used.6 For some framings and improvement methods, culture is
key; for others, cultural aspects are in the background. Our view
is that the cultural dimensions of organisations are an important
substrate on which improvement focused change is being sought
and that, although never fully manageable, cultures can be better
understood and must be purposefully shaped.
Finally, the cultural framing of healthcare organisations draws
attention to specific aspects of organisational life: the shared
patterns of feeling, thinking, talking, and accomplishing that
underpin local practice. In doing so, other equally important
aspects of organisational life may be marginalised or neglected,
such as individual skill, attitude, and responsibility; governance
and performance management arrangements; the macro
structural arrangements within which local service lines are
embedded; the incentives spread across the system; and the
availability of material resources, human capital, and knowledge.
Each of these aspects interacts with and can sometimes
overwhelm cultural features, with a resultant effect on the ability
to shape and improve culture and services. The choice to focus
improvement efforts on healthcare culture to the exclusion of,
say, policy frameworks or resource constraints, inevitably has
political ramifications, and these should be dealt with rather
than ignored. Cultural reform in healthcare is no substitute for
adequate resourcing. That said, the cultural perspective outlined
here provides an insightful way of thinking and a practical set
of tools to support wider quality improvement work in
healthcare.
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ANALYSIS
BMJ: first published as 10.1136/bmj.k4907 on 28 November 2018. Downloaded from http://www.bmj.com/ on 30 November 2022 at University of N S Wales 1247645. Protected by copyright.
Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is one of a series commissioned by The BMJ based on ideas generated
by a joint editorial group with members from the Health Foundation and The BMJ,
including a patient/carer. The BMJ retained full editorial control over external peer
review, editing, and publication. Open access fees and The BMJ’s quality
improvement editor post are funded by the Health Foundation.
1 Francis R. The Mid Staffordshire NHS Foundation Trust public inquiry. 2013. https://www.
gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-
inquiry
2 Kennedy I. The Report of the Public Inquiry into children’s heart surgery at the Bristol
Royal Infirmary 1984-1995. Learning from Bristol. 2001. https://psnet.ahrq.gov/resources/
resource/5187/learning-from-bristol-the-report-of-the-public-inquiry-into-childrens-heart-
surgery-at-the-bristol-royal-infirmary-1984-1995
3 Gosport Independent Panel. Gosport War Memorial Hospital: the report of the Gosport
independent panel. 2018. https://www.gosportpanel.independent.gov.uk/
4 Dixon-Woods M, Baker R, Charles K, etal . Culture and behaviour in the English National
Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf
2014;23:106-15. 10.1136/bmjqs-2013-001947 24019507
5 Davies HT, Mannion R. Will prescriptions for cultural change improve the NHS?BMJ
2013;346:f1305. 10.1136/bmj.f1305 23457210
6 Powell AE, Rushmer RK, Davies HTO. A systematic narrative review of quality
improvement models in health care. NHS Quality Improvement Scotland, 2009.
7 Schein E. Organizational culture and leadership. Jossey Bass, 1985.
8 Mannion R. Davies, H Cultures in Healthcare. In: Ferlie E, Montgomery K, Reff Pedersen
A, eds. Oxford Handbook of Health Care Management. Oxford University Press, 2016.
9 Powell AE, Davies HTO. The struggle to improve patient care in the face of professional
boundaries. Soc Sci Med 2012;75:807-14. 10.1016/j.socscimed.2012.03.049 22633159
10 Davies HT, Nutley SM, Mannion R. Organisational culture and quality of health care. Qual
Health Care 2000;9:111-9. 10.1136/qhc.9.2.111 11067249
11 Jung T, Scott T, Davies H, Bower P, Mannion R. Instruments for the exploration of
organizational culture. Public Adm Rev
2009;69:1987-109610.1111/j.1540-6210.2009.02066.x .
12 Jung T, Scott T, Davies H, Bower P, Mannion R. Instruments for the exploration of
organizational culture. Public Adm Rev
2009;69:1987-9610.1111/j.1540-6210.2009.02066.x.
13 Scott T, Mannion R, Marshall M, Davies H. Does organisational culture influence health
care performance? A review of the evidence. J Health Serv Res Policy 2003;8:105-17.
10.1258/135581903321466085 12820673
14 Braithwaite J, Herkes J, Ludlow K, Testa L, Lamprell G. Association between organisational
and workplace cultures, and patient outcomes: systematic review. BMJ Open
2017;7:e017708. . 10.1136/bmjopen-2017-017708 29122796
15 Curry LA, Brault MA, Linnander EL, etal . Influencing organisational culture to improve
hospital performance in care of patients with acute myocardial infarction: a mixed-methods
intervention study. BMJ Qual Saf 2018;27:207-17. 10.1136/bmjqs-2017-006989 29101292
16 Bradley EH, Brewster AL, McNatt Z, etal . How guiding coalitions promote positive culture
change in hospitals: a longitudinal mixed methods interventional study. BMJ Qual Saf
2018;27:218-25. 10.1136/bmjqs-2017-006574 29101290
17 Shortell SM, Marsteller JA, Lin M, etal . The role of perceived team effectiveness in
improving chronic illness care. Med Care 2004;42:1040-8.
10.1097/00005650-200411000-00002 15586830
18 Gerowitz MB, Lemieux-Charles L, Heginbothan C, Johnson B. Top management culture
and performance in Canadian, UK and US hospitals. Health Serv Manage Res
1996;9:69-78. 10.1177/095148489600900201 10156914
19 Jacobs R, Mannion R, Davies HTO, Harrison S, Konteh F, Walshe K. The relationship
between organizational culture and performance in acute hospitals. Soc Sci Med
2013;76:115-25. 10.1016/j.socscimed.2012.10.014 23159305
20 Mannion R, Davies HT, Marshall MN. Cultural characteristics of “high” and “low” performing
hospitals. J Health Organ Manag 2005;19:431-9. 10.1108/14777260510629689 16375066
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